“You don’t have to have it all figured out to begin. Let’s take the next step together” Name * First Name Last Name Name of Person Submitting Form if Different From Client First Name Last Name Email * Phone (###) ### #### Date of Birth MM DD YYYY Location Preference * Virtual In-Person (Brentwood) Days Available to Schedule * Mondays (virtual only) Tuesdays (virtual only) Wednesday's (Virtual or In-person) Fridays (Virtual or In-Person) Saturdays (Virtual or In-Person) Sundays (Virtual only) Times Available to Schedule * Mornings Afternoons Evenings Flexible Form of Payment? * Self-Pay Out-of-Pocket Preferred Date MM DD YYYY How did you hear about us? Please give us a brief description as to why you are seeking services * Thank you!
